Provider Demographics
NPI:1306040936
Name:PHUNG, QUENTIN (MD)
Entity Type:Individual
Prefix:
First Name:QUENTIN
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 OLD PLANK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3107
Mailing Address - Country:US
Mailing Address - Phone:518-371-0777
Mailing Address - Fax:518-371-0366
Practice Address - Street 1:9 OLD PLANK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3107
Practice Address - Country:US
Practice Address - Phone:518-371-0777
Practice Address - Fax:518-371-0366
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA234866171100000X
NY234866208VP0000X, 2081P2900X
NY234866-12081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No171100000XOther Service ProvidersAcupuncturist
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000418627001OtherBSNENY PIN - SPECIALIST
NY03056902Medicaid
NY000418627005OtherBSNENY PIN - ACUPUNTURIST